Exam 1 - Starting the Physical Examination: General Survey and Vital Signs Flashcards
Components of the general survey
Apparent state of health
>Acute or chronically ill, frail
Level of consciousness
>Awake, alert, responsive or lethargic, obtunded, comatose
Signs of distress
>Cardiac or respiratory; pain; anxiety/depression
Skin color and obvious lesions
You walk into a patient’s exam room and what do you see?
Mental notes of the patient’s affect, body habitus, development, weight, height, overall hygiene, alertness and orientation
Document what you discover
How do you document personal hygiene and orientation?
Dress, grooming, and personal hygiene Appropriate to weather and temperature Clean, properly buttoned/zipped Odors of body and breath Posture, gait, and motor activity
How do you document facial expression?
Facial expression
Eye contact, appropriate changes in facial expression
How do you describe height?
Measure in stocking feet
Short or tall
Build: slender and lanky, muscular, or stocky
Body symmetry
Note general body proportions and any deformities
How do you describe weight?
Weight
Emaciated, slender, plump, obese
If obese, is fat distributed evenly or concentrated over trunk, upper torso, or around the hips?
Can calculate BMI from this.
Body Mass Index
BMI = (Weight * 700) / (height in inches squared)
When a BMI is greater than 35, why do you measure the hips of the patient?
If > 35 inches for women or if > 40 inches for men, they’re at an INCREASED risk for–
DM
HTN
Cardiovascular disease
**BMI skewed if very muscular or if muscle wasting
EXAMPLES of General Survey
Normal:
The patient is a well-developed, well-nourished middle aged male, appropriately dressed for the weather.
Patient is AAO x 3, well-developed, well-nourished, in no acute distress.
AAO x 3 = alert and oriented to person, place, time
Psych pt:
Patient with labile affect, oriented only to self, exhibiting poor hygiene and inappropriate behavior.
Vital signs
Blood pressure
Heart rate and rhythm
Respiratory rate and rhythm
Temperature
Important part of assessment & reassessment
Points you in a direction for the visit
If abnormal, you recheck them
“True blood pressure”
Average over many days/weeks
It is the patient’s real reading
During encounter “office measurement”
Room for error
Anxiety, stress, “white coat syndrome”
Measurement error
Physiologic fluctuations
White coat HTN
White coat HTN
Low regular readings at home but elevated in the office
Low risk of cardiovascular disease
Masked HTN
Masked HTN
Elevated readings at home but low in the office
High risk of cardiovascular disease
Hypertension
JNC 8 classifies HTN as anything >150/90
Optimal conditions to take BP
Patient to avoid smoking or drinking caffeinated beverages 30 minutes prior to measurement
Ensure that the room is quiet and comfortably warm
Patient should be seated quietly in a chair with feet on the floor for at least 5 minutes
Patient’s arm should be FREE of clothing
Palpate the brachial artery
Position the arm so that the brachial artery is at heart level
Rest the arm on a table a little above the patient’s waist, or support the patient’s arm with your own at his mid-chest level
Cuff size and width
Width of the bladder: 40% of upper arm circumference
Length of the bladder: 80% of upper arm circumference
How do you determine what pressure to pump cuff to?
With the fingers of your opposite hand, palpate the radial artery and inflate the cuff until the radial pulse disappears; add 30 mm Hg to this pressure
Korotkoff Sounds
The point at which you hear the first two consecutive beats is the systolic pressure = Korotkoff sounds
If BP differs by more than 5mmHg, then?
Repeat BP.
Take it in BOTH arms at least ONCE throughout the visit.
Signs of subclavian steal syndrome or aortic dissection
Difference in pressure of about 5-10 mm Hg
Any more than this value could be subclavian steal syndrome or aortic dissection
Auscultory Gap
A silent interval that may be present between the systolic and diastolic blood pressures; i.e., the sound disappears for a while, then reappears. Can be associated with atherosclerotic disease and arterial stiffness.
Orthostatic BP
Measure blood pressure and heart rate with the patient supine; wait 3 minutes, then have the patient stand up; now repeat the measurements (or lay down, sit, stand)
Inaudible Korotkoff sounds
Check equipment
Adjust stethoscope
Make sure you place it in your ears correctly
Ensure inflation of bladder
Obese Patient
Large cuff/thigh cuff
Beware of taking BP in forearm
False readings
What’s use to measure heart rate? What’s a normal heart rate?
Radial pulse; 50-90 BPM.
If the rate is fast or slow and/or the rhythm is irregular, count for a full 60 seconds.
Heart Rhythm - Feel for rhythm during. What do you do when irregular?
Is there a pattern to the irregularity?
It the rhythm associated with respirations?
Is it irregularly irregular?
COMPARE by listening to APEX of heart.
Follow up with 12 lead EKG if irregularity is noted.
Normal Respiratory Rate
20 breaths per minute (14-20)
Observe rhythm: regular, irregular
Observe depth: shallow, gasping
Observe effort: normal, labored
Bradypnea
refers to an abnormally slow breathing rate.
Hyperventilation
Hyperventilation is rapid or deep breathing that can occur with anxiety or panic. It is also called overbreathing, and it may leave you feeling breathless.
Tachypnea
abnormally rapid breathing.
Obstructive breathing
Prolonged expiration; COPD patients
Cheyne-Stokes Respirations
is an abnormal pattern of breathing characterized by progressively deeper and sometimes faster breathing, followed by a gradual decrease that results in a temporary stop in breathing called an apnea.
Average oral temperature:
37°C or 98.6°F
Diurnal variation:
35.8°C (96.4°F) to 37.3°C (99.1°F)
Pyrexia
fever, elevated body temperature
Hyperpyrexia
> 106˚F
Hypothermia
=
Glass thermometers
Shake them down to below 96˚
Insert under tongue/close lips
Wait 3-5 minutes
Electronic thermometers
Place disposable cover on tip
Insert under tongue/close lips
10 seconds
When do you take rectal temperatures?
Indications
Unconscious
Restless
Unable to close mouths
Performance:
Lie on side, one hip flexed
Lubricate tip, insert (electronic) thermometer
10 seconds
Most common: Tympanic Temps.
Quick, safe, reliable if performed correctly
Canal clear (cerumen will give lower reading)
Aim beam at TM
2-3 seconds
Measuring core temp, warmer than oral temp
PAIN
Unpleasant sensory and emotional experience
Involves sensory, emotional, cognitive processing
May lack physical etiology
Chronic Pain
Pain not associated with cancer or other medical problems lasting more than 3-6 months
Pain lasting more than 1 month beyond course of an acute illness or injury
Pain recurring at intervals of months-years
Assess location, severity, associated features, attempted treatments, medications, related illnesses, impact on daily activities
Nociceptive or somatic pain
related to tissue damage
Neuropathic pain
resulting from direct trauma to the peripheral or central nervous system
Psychogenic
relates to factors that influence the patient’s report of pain >Psychiatric conditions >Personality and coping style >Cultural norms >Social support systems
Idiopathic
no identifiable etiology
What is the difference between orthostatic and normal blood pressure?
Normal: systolic BP drops slightly or remains unchanged; diastolic BP rises slightly
Orthostasis: systolic BP drops >20 mm Hg or diastolic BP drops >10 mm Hg
